Mucogingival Surgery and Perio-Plastic Procedures Overview

ITS DENTAL COLLEGE,HOSPITAL AND RESEARCH
CENTRE,GREATER NOIDA
Introduction
Aberrant frenum
Inadequacy of attached gingiva
Inadequate/ shallow depth of vestibule
Mucogingival surgery/ Perioplastic Surgery
Conclusion
CONTENTS
The 
mucogingival complex 
consists of free and attached
gingiva, mucogingival junction (MGJ) and the alveolar mucosa .
A 
mucogingival problem 
is defined as the presence of gingival
inflammation and gingival recession in areas with little or no
attached gingiva
The 
consequences of mucogingival problems 
could be,
1.
Pocket formations
: due to a close disruption of the complex.
2.
Gingival clefts and gingival recession
INTRODUCTION
Goldman 
1 
was the first to point out the limitations of
mucogingival topography upon periodontal surgery.
Goldman
1
 
emphasized particularly that
SHALLOW VESTIBULE 
leads to
Therefore, the 
concept of mucogingival surgery 
encompassed
two intimately associated aims,
 
the alteration of vestibulär fornix depth 
and
the production of a 
new and wider zone of attached gingiva
 
food impaction against
 the gingival margin and
 into the interproximal spaces
,
difficult for the patient to place the
toothbrush properly
and cleanse the area.
MUCOGINGIVAL SURGERY
Term  was initially introduced  by 
Friedman
2
(1957)
Surgical procedures for correction of relationships between gingiva
and oral mucous membrane with reference to three specific problem
areas:
1.
Attached gingiva
,
2.
Shallow 
vestibule, 
and
3.
Frenum
 interfering with marginal gingiva
 
MUCOGINGIVAL THERAPY
(1996 World Workshop in Periodontics
 )
 
The 
Consensus Report
 
from  1996 World Workshop in
Periodontics
 defines
 
Mucogingival Therapy
     as “
non-surgical and 
surgical 
correction of defects
      in morphology, position, and/or amount of
      
soft tissue 
and underlying 
bone
&
Periodontal Plastic Surgery
 as “
surgical
 procedures performed to prevent or correct
A
natomical, 
D
evelopmental, 
T
raumatical, or 
P
laque disease-induced defects of the
   gingiva, alveolar mucosa, or bone.”
Mucogingival surgery
 (Friedman)
Periodontal plastic surgery
3
Term originally by Preston D.Miller (1993)
1996 World Workshop in Periodontics 
renamed
mucogingival surgery as periodontal plastic surgery
Goldman and Cohen
TISSUE BARRIER CONCEPT
for
mucogingival surgery.
Dense collagenous band of connective tissue
retards or obstructs the spread of inflammation
better than does the loose fiber arrangement of the
alveolar mucosa. They recommended increasing the
zone of keratinized attached tissue to achieve an
adequate tissue barrier, “
 
ABERRANT FRENUM
Definition
There are several frena that are usually present in a normal oral
cavity, most notably
1.
the maxillary labial frenum,
2.
the mandibular labial frenum, and
3.
 the lingual frenum.
A frenum is a 
mucous membrane fold which contains
muscle and connective tissue fibres 
that attach the 
lip and
the cheek to the alveolar mucosa, the gingiva and the
underlying periosteum.
4
 
Median Maxillary Labial Frenum 
(MMLF
)
The MMLF is a 
posteruptivem remnant of the tectolabial
bands
.
4,5
Histologically, the MMLF consists of
 a stratified squamous epithelium
that covers highly vascular, loose fibrous connective tissue,
 abundance of elastic fibers.
4-6
As the primary teeth erupt, the height in the alveolar structures
increases normally and the attachment of the frenum moves
superiorly with the maxillary alveolar crest
C
l
a
s
s
i
f
i
c
a
t
i
o
n
.
.
.
Depending upon the extension of attachment of  frena have been
classified as by Placek et al (1974)
8
.
1. 
Mucosal
 – when the frenal fibres are attached up to the
mucogingival junction.
2. 
Gingival
 – when the fibres are inserted within the attached
gingiva.
3. 
Papillary
 – when the fibres extending into the interdental papilla.
4. 
Papilla penetrating 
– when the frenal fibres cross the alveolar
process and extend up to the palatine papilla.
SOME OTHER VARIATIONS
                            
Simple frenum with nichum
Simple frenum with appendix
Wider frenal attachment
Simple frenum with a nodule
Aberrant frenum(pathogenic frenum)/
Indications of frenectomy or frenotomy
1.
An aberrant frenal attachment is present, which causes a
midline diastema
.
The 
current consensus
 among clinicians
 the diastema needs to be 
corrected  initially with orthodontic
treatment 
and subsequent retention, (Fig ).
Soft tissue surgery should be initiated only after the diastema has
been closed.
 This is necessary to avoid 
possible postoperative scar tissue that
may interfere with orthodontic treatment.
 
2
.   A flattened papilla with the frenum 
closely attached to the
gingival margin 
is present, which causes a
gingival recession
               
and
a hindrance in 
maintaining the
       oral hygiene.
3. An aberrant frenum with an 
inadequately attached gingiva and
     a shallow vestibule 
is seen.
Diagnosis
Tension test : Kopczyk  RA(1974)
15
The abnormal frena are detected visually
 by applying tension
over the frenum to see
 the 
movement 
of the papillary tip
                                or
 the 
blanch
 which is produced due to ischemia in the region.
PULL SYNDROME
   Detaching movement of marginal gingiva transferred from lip
by frenum
Treatment
The aberrant frena can be treated by 
frenectomy or by frenotomy
procedures.
 
Frenectomy
  is the complete removal of the frenum, including its
attachment to the underlying bone.
Frenotomy
 is the incision and the relocation of the frenal
attachment.
3
The techniques which were employed were:
• Conventional (Classical) frenectomy
• Miller’s technique
• V-Y Plasty
• Z Plasty
• Frenectomy which was done by using electrocautery
 
INADEQUACY OF ATTACHED GINGIVA
GINGIVA..
The  gingiva is that part of oral mucous membrane attached to
the teeth and alveolar process of the jaws and surrounds neck
of the teeth
It consists of three parts:-
1)
Attached gingiva
2)
Interdental gingiva
3)
Marginal gingiva
According to glossary of periodontal
term (1972
)
Attached gingiva is that portion of
gingiva that extends from the base
of  gingival crevice to mucogingival
junction.
A
T
T
A
C
H
E
D
 
G
I
N
G
I
V
A
IMPORTANCE OF ATTACHED GINGIVA
1.
It bears the 
masticatory forces.
2.
Withstand forces of toothbrushing
3.
It acts as a 
brace
 prevents movement of mobile tissues
               (marginal gingiva and alveolar mucosa)
4.
Its 
firm attachment to the underlying periosteum  
:
a.
Prevents 
displacement of marginal gingiva away from tooth
which may expose the root surface 
and
b.
Leave it vulnerable to action of external stimuli  may cause
root sensitivity.
Importance of width of attached gingiva
It should be increased in following conditions:-
1.
Patient’s plaque control is compromised
2.
Prosthetic restorations
3.
Orthodontic treatment
4.
When pocket depth extends beyond the alveolar mucosa
5.
In cases of abnormal frenal attachment
M
E
A
S
U
R
E
M
E
N
T
 
O
F
 
W
I
D
T
H
 
O
F
 
A
T
T
A
C
H
E
D
G
I
N
G
I
V
A
HALL
11
 said that the width of attached gingiva is determined
by subtracting the sulcus or pocket depth from total width of
gingiva
Methods to determine mucogingival junction:
1. Visual method.
2. Functional method.
3. Visual methods after histochemistry staining.
Methods of measuring width of attcahed gingiva
and checking its adequacy
1. VISUAL METHOD
:-
 
the amount  of attached gingiva is
generally considered to be insufficient when 
streching of
the lip or cheek 
induces movement of the free gingival
margin
 (
TENSION TEST).
TENSION TEST
2. HISTOCHEMICAL STAINING
painting of oral mucosa with ‘
schiller’s potassium iodide
which stains 
nonkeratinized area.
IODINE TEST USING SCHILLER’S OR LUGOL’S SOLUTION
3. Bowers' method
Clinical method:-
1.
Step1:-
measure the probing depth
(from gingival margin to base of
the sulcus.
2.
Step2:-
measure the total width of
gingiva from gingival margin to
mucogingival line
3.
Step3:-
calculate the width of
attached gingiva by subtracting
the probing depth from total width
of the gingiva
(Total gingival width-pocket
depth=width of attached gingiva)
MEASURING DEPTH OF THE POCKET
MEASURING TOTAL WIDTH OF
ATTACHED GINGIVA
4. ROLL TEST
:-
It is done by 
pushing the adjacent mucosa coronally 
with a
dull instrument to demarcate mucogingival line.
If the gingiva moves with the instrument then width of attached
gingiva is considered inadequate.
ROLL TEST
 
 
INADEQUATE WIDTH OF ATTACHED GINGIVA:
 
Friedman 
stated that ‘‘inadequate’’ zone of gingiva would
facilitate movability of the Marginal tissue.
 
1.
People 
without sufficient attached gingiva, resulting in the
muscles in alveolar mucosa to pull the gingiva down
.
Gingival recession as well as bone loss is seen.
2.
Abnormal frenal attachment
, which exaggerates the pull on
gingival margin.
 
INADEQUATE /SHALLOW WIDTH OF VESTIBULE
VESTIBULE
The mouth, consists of two regions, the 
vestibule
 and the
oral
 cavity proper.
 The 
vestibule
 is the area between the teeth, lips and
cheeks.
The 
oral
 cavity is bounded at the sides and in front by the
alveolar process (containing the teeth) and at the back by
the isthmus of the fauces
V
e
s
t
i
b
u
l
e
 
(
v
e
s
t
i
b
u
l
u
m
 
o
r
i
s
)
bounded :
externally by the lips and cheeks
 internally by the gums and teeth.
 It communicates with the surface of
the body by the 
orifice of the
mouth.
Above and below, it is limited by the
reflection of the mucous membrane
from the lips and cheeks to the gum
covering the upper and lower
alveolar arch respectively.
 
 Depth of Vestibular Fornix
The depth of the vestibule fornix has been defined in two ways:
the upper limit of the vestibule
either being taken as the crest of the lip ,or
the coronal margin of the attached gingiva;
the lower limit of the vestibule 
being the mucobuccal fold.
The depth of fornix measured from the 
crest of the Lip to the
mucobuccal fold
 varied from a maximum of 29 mm to a
minimum of 10 mm.
Management
 
MUCOGINGIVAL SURGERY
1. FREE GINGIVAL AUTOGRAFT
Described by MILLER
Step1:-
 ROOT PLANING-
Step2-
 PREPARE THE RECIPIENT SITE
Step3-
 OBTAIN GRAFT FROM DONOR SITE – Proper
thickness of graft of about 1-1.5mm
 is necessary for graft
survival.
Step 4-
 TRANSFER & IMMOBILIZE THE GRAFT
Step 5- 
PROTECT THE DONOR SITE
 
 
 
Healing takes 
10.5wks for 0.75mm graft & 16 wks for
1.75mm graft
.
COLOR
 - As the graft vessels are empty so 
graft is pale that
changes to grayish white during 2 days
.
CONSISTENCY
 -Plasmatic circulation accumulates and
causes softening & swelling of graft which reduces as new
blood vessels form.
Functional integration occurs by 17
th
 day but the tissue is
mophologically distinct for months.
After 24 weeks graft shrinks 25% when placed on denuded
bone & 50% when placed on periosteum.
2.PEDICLE AUTOGRAFT
LATERALLY (HORIZONTALLY) DISPLACED
FLAPS-
Described by GRUPE & WARREN- 
STEPS-
STEP 1- PREPARE THE RECIPIENT BED-
STEP 2- PREPARE THE FLAP
STEP 3- TRANSFER THE FLAP
STEP 4- PROTECT THE FLAP & DONOR SITE
 
 
 
CORONALLY DISPLACE FLAP-
STEP 1- Two vertical incisons beyond mucogingival
   junction. Elevate flap
STEP 2-  Scale &
 root plane tooth
              suface.
STEP3- return flap
   & suture it.
 
 
3. SUBEPITHELIAL CONNECTIVE TISSUE
GRAFT ( LANGER)
 
Indicated for multiple defects with good vestibular depth and
gingival thickness.
STEPS-
STEP 1-
 2 horizontal incison & two vertical incisons extending 1
-2 mm away from gingival margin. Extend the flap to
mucobuccal fold.
STEP 2-
 Scale & root planing
STEP 3-
 Obtain connective tissue graft from palate.
STEP 4-
 Place connective tissue on denuded root surface &
suture it.
STEP 5-
 Cover the graft with partial thickness flap & suture it
interdentally
 
 
bibliography
1.
Goldman, H. M., PERIODONTIA. Ed. J, St.
Louis, 1953, C. V. Mosby Co., pp. 552-561
2.
Friedman N. Mucogingival surgery. 
Tex Dent J 1957;
75:358-362
3.
Consensus report on mucogingival therapy. 
Ann Periodontol 
1996;1:702-706
4.
Dewel BF. The normal and the abnormal labial frenum: clinical differentiation. J Am Dent Assoc. 1946;33:318-
329.
5.
Henry SW, Levin MP, Tsaknis PJ. Histologic features of superior labial frenum. J Periodontol. 1976;47(1):25-28.
6.
Bhaskar SN, ed. Orban’s Oral Histology and Embryology.11th ed. St. Louis, MO: Mosby Year Book; 1991:301.
7.
Sewerin I. Prevalence of variations and anomalies of the upper labial frenum. Acta Odontol Scand. 1971;
29(4):487-496
8.
Mirko P,  Miroslav S, Lubor M. Significance of the labial frenum attachment in periodontal disease in man. Part
I. Classification and epidemiology of the labial frenum attachment. J Periodontol 1974;45:891‑4.
9.
Angle EH: Treatment of malocclusion of the teeth, 7th Ed. Philadelphia: SS White Co, 1907.
10.
Tait CN: The median fraenum of the upper lip and its influence on the spacing of the upper central incisor teeth.
NewZealand Dent J 20:5-21, 47-65, 1929.
11.
Ceremello PJ: The superior labial frenum and the midline diastema and their relation to growth and development
ofthe oral structures. Am J Orthodont 39:120-39, 1933.
12.
Aa
13.
Bb
14.
Friedman N, Levine HL: Mucogingival surgery. JPeriodontol 35:5-21, 1964
15.
Kopczyk RA, Saxe SR. Clinical signs of gingival inadequacy: the tension test.ASDC J Dent
Child.1974;41(5):352-5
 
16.
Ainamo J, Loe H: Anatomical characteristics of gingiva.
A Clinical and microscopic study of the free and
attached Gingiva. J Periodontol 1996; 37:5.
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The article discusses mucogingival surgery and perio-plastic procedures, focusing on issues like aberrant frenum, inadequate attached gingiva, and shallow vestibule. It explores the importance of these surgical interventions in addressing gingival inflammation, recession, and other mucogingival problems. The history, techniques, and outcomes of mucogingival surgery are detailed, highlighting the significance of enhancing vestibular depth and creating a wider zone of attached gingiva. Additionally, the World Workshop in Periodontics' definitions of mucogingival therapy and periodontal plastic surgery are explained, emphasizing the non-surgical and surgical correction of soft tissue and bone defects related to the gingiva and mucosa.


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  1. Mucogingival Surgery & Perio-Plastic Procedures ITS DENTAL COLLEGE,HOSPITAL AND RESEARCH CENTRE,GREATER NOIDA

  2. CONTENTS Introduction Aberrant frenum Inadequacy of attached gingiva Inadequate/ shallow depth of vestibule Mucogingival surgery/ Perioplastic Surgery Conclusion

  3. INTRODUCTION The mucogingival complex consists of free and attached gingiva, mucogingival junction (MGJ) and the alveolar mucosa . A mucogingival problem is defined as the presence of gingival inflammation and gingival recession in areas with little or no attached gingiva The consequences of mucogingival problems could be, Pocket formations: due to a close disruption of the complex. Gingival clefts and gingival recession 1. 2.

  4. Goldman 1 was the first to point out the limitations of mucogingival topography upon periodontal surgery. Goldman1emphasized particularly that SHALLOW VESTIBULE leads to food impaction against the gingival margin and into the interproximal spaces, difficult for the patient to place the toothbrush properly and cleanse the area. Therefore, the concept of mucogingival surgery encompassed two intimately associated aims, the alteration of vestibul r fornix depth and the production of a new and wider zone of attached gingiva

  5. MUCOGINGIVAL SURGERY Term was initially introduced by Friedman2(1957) Surgical procedures for correction of relationships between gingiva and oral mucous membrane with reference to three specific problem areas: Attached gingiva, Shallow vestibule, and Frenum interfering with marginal gingiva 1. 2. 3.

  6. MUCOGINGIVAL THERAPY (1996 World Workshop in Periodontics ) SURGICAL PROCEDURES Periodontal plastic surgery NON-SURGICAL PROCEDURES Papilla reconstruction by means of Orthodontic or Restorative therapy.

  7. The Consensus Report from 1996 World Workshop in Periodontics defines Mucogingival Therapy as non-surgical and surgical correction of defects in morphology, position, and/or amount of soft tissue and underlying bone & Periodontal Plastic Surgery as surgical procedures performed to prevent or correct Anatomical, Developmental, Traumatical, or Plaque disease-induced defects of the gingiva, alveolar mucosa, or bone.

  8. Mucogingival surgery (Friedman) Goldman and Cohen TISSUE BARRIER CONCEPT for mucogingival surgery. Dense collagenous band of connective tissue retards or obstructs the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa. They recommended increasing the zone of keratinized attached tissue to achieve an adequate tissue barrier, Periodontal plastic surgery3 Term originally by Preston D.Miller (1993) 1996 World Workshop in Periodontics renamed mucogingival surgery as periodontal plastic surgery

  9. Mucogingival deformity Surgery indicated vestibular deepening 1. Shallow vestibule frenectomy 2. Aberrant frenum soft tissue grafting 3. Marginal tissue recession 4. Excessive gingival display crown lengthening 5. Deficient ridges ridge augmentation 6. Ridge collapse following extraction of periodontally involved teeth grafting extraction sites 7. Loss of interdental papillae papilla reconstruction 8. Unerupted teeth requiring orthodontic movement surgical exposure 9. Aesthetic defects around dental implants bone and or soft tissue augmentation

  10. ABERRANT FRENUM

  11. Definition There are several frena that are usually present in a normal oral cavity, most notably the maxillary labial frenum, the mandibular labial frenum, and the lingual frenum. 1. 2. 3. A frenum is a mucous membrane fold which contains muscle and connective tissue fibres that attach the lip and the cheek to the alveolar mucosa, the gingiva and the underlying periosteum.4

  12. Median Maxillary Labial Frenum (MMLF) The MMLF is a posteruptivem remnant of the tectolabial bands.4,5 Histologically, the MMLF consists of a stratified squamous epithelium that covers highly vascular, loose fibrous connective tissue, abundance of elastic fibers.4-6 As the primary teeth erupt, the height in the alveolar structures increases normally and the attachment of the frenum moves superiorly with the maxillary alveolar crest

  13. Classification... Depending upon the extension of attachment of frena have been classified as by Placek et al (1974)8. 1. Mucosal when the frenal fibres are attached up to the mucogingival junction. 2. Gingival when the fibres are inserted within the attached gingiva. 3. Papillary when the fibres extending into the interdental papilla. 4. Papilla penetrating when the frenal fibres cross the alveolar process and extend up to the palatine papilla.

  14. SOME OTHER VARIATIONS Simple frenum with appendix Simple frenum with a nodule Simple frenum with nichum Wider frenal attachment

  15. Aberrant frenum(pathogenic frenum)/ Indications of frenectomy or frenotomy An aberrant frenal attachment is present, which causes a midline diastema. 1.

  16. The current consensus among clinicians the diastema needs to be corrected initially with orthodontic treatment and subsequent retention, (Fig ). Soft tissue surgery should be initiated only after the diastema has been closed. This is necessary to avoid possible postoperative scar tissue that may interfere with orthodontic treatment.

  17. 2. A flattened papilla with the frenum closely attached to the gingival margin is present, which causes a gingival recession and a hindrance in maintaining the oral hygiene. 3. An aberrant frenum with an inadequately attached gingiva and a shallow vestibule is seen.

  18. Diagnosis Tension test : Kopczyk RA(1974)15 The abnormal frena are detected visually by applying tension over the frenum to see the movement of the papillary tip or the blanch which is produced due to ischemia in the region. PULL SYNDROME Detaching movement of marginal gingiva transferred from lip by frenum

  19. Treatment The aberrant frena can be treated by frenectomy or by frenotomy procedures. Frenectomy is the complete removal of the frenum, including its attachment to the underlying bone. Frenotomy is the incision and the relocation of the frenal attachment.3 The techniques which were employed were: Conventional (Classical) frenectomy Miller s technique V-Y Plasty Z Plasty Frenectomy which was done by using electrocautery

  20. INADEQUACY OF ATTACHED GINGIVA

  21. GINGIVA.. The gingiva is that part of oral mucous membrane attached to the teeth and alveolar process of the jaws and surrounds neck of the teeth It consists of three parts:- Attached gingiva Interdental gingiva Marginal gingiva 1) 2) 3)

  22. ATTACHED GINGIVA According to glossary of periodontal term (1972) Attached gingiva is that portion of gingiva that extends from the base of gingival crevice to mucogingival junction.

  23. IMPORTANCE OF ATTACHED GINGIVA It bears the masticatory forces. 1. Withstand forces of toothbrushing 2. It acts as a brace prevents movement of mobile tissues 3. (marginal gingiva and alveolar mucosa) Its firm attachment to the underlying periosteum : Prevents displacement of marginal gingiva away from tooth which may expose the root surface and Leave it vulnerable to action of external stimuli may cause root sensitivity. 4. a. b.

  24. MEASUREMENT OF WIDTH OF ATTACHED GINGIVA HALL11 said that the width of attached gingiva is determined by subtracting the sulcus or pocket depth from total width of gingiva Methods to determine mucogingival junction: 1. Visual method. 2. Functional method. 3. Visual methods after histochemistry staining.

  25. Methods of measuring width of attcahed gingiva and checking its adequacy 1. VISUAL METHOD:-the amount of attached gingiva is generally considered to be insufficient when streching of the lip or cheek induces movement of the free gingival margin (TENSION TEST). TENSION TEST

  26. 2. HISTOCHEMICAL STAINING painting of oral mucosa with schiller s potassium iodide which stains nonkeratinized area. IODINE TEST USING SCHILLER S OR LUGOL S SOLUTION

  27. 3. Bowers' method Clinical method:- Step1:-measure the probing depth (from gingival margin to base of the sulcus. Step2:-measure the total width of gingiva from gingival margin to mucogingival line Step3:-calculate the width of attached gingiva by subtracting the probing depth from total width of the gingiva 1. 2. MEASURING DEPTH OF THE POCKET 3. (Total gingival width-pocket depth=width of attached gingiva) MEASURING TOTAL WIDTH OF ATTACHED GINGIVA

  28. 4. ROLL TEST:- It is done by pushing the adjacent mucosa coronally with a dull instrument to demarcate mucogingival line. If the gingiva moves with the instrument then width of attached gingiva is considered inadequate. ROLL TEST

  29. INADEQUATE WIDTH OF ATTACHED GINGIVA: Friedman stated that inadequate zone of gingiva would facilitate movability of the Marginal tissue. People without sufficient attached gingiva, resulting in the muscles in alveolar mucosa to pull the gingiva down. Gingival recession as well as bone loss is seen. Abnormal frenal attachment, which exaggerates the pull on gingival margin. 1. 2.

  30. INADEQUATE /SHALLOW WIDTH OF VESTIBULE

  31. VESTIBULE The mouth, consists of two regions, the vestibule and the oral cavity proper. The vestibule is the area between the teeth, lips and cheeks. The oral cavity is bounded at the sides and in front by the alveolar process (containing the teeth) and at the back by the isthmus of the fauces

  32. Vestibule (vestibulum oris) https://classconnection.s3.amazonaws.com/287/flashcards/1274287/png/untitled1343699882737.png bounded : externally by the lips and cheeks internally by the gums and teeth. It communicates with the surface of the body by the orifice of the mouth. Above and below, it is limited by the reflection of the mucous membrane from the lips and cheeks to the gum covering the upper and lower alveolar arch respectively.

  33. Depth of Vestibular Fornix The depth of the vestibule fornix has been defined in two ways: the upper limit of the vestibule either being taken as the crest of the lip ,or the coronal margin of the attached gingiva; the lower limit of the vestibule being the mucobuccal fold. The depth of fornix measured from the crest of the Lip to the mucobuccal fold varied from a maximum of 29 mm to a minimum of 10 mm.

  34. MUCOGINGIVAL SURGERY

  35. 1. FREE GINGIVAL AUTOGRAFT Described by MILLER Step1:- ROOT PLANING- Step2- PREPARE THE RECIPIENT SITE Step3- OBTAIN GRAFT FROM DONOR SITE Proper thickness of graft of about 1-1.5mm is necessary for graft survival. Step 4- TRANSFER & IMMOBILIZE THE GRAFT Step 5- PROTECT THE DONOR SITE

  36. Healing takes 10.5wks for 0.75mm graft & 16 wks for 1.75mm graft. COLOR - As the graft vessels are empty so graft is pale that changes to grayish white during 2 days. CONSISTENCY -Plasmatic circulation accumulates and causes softening & swelling of graft which reduces as new blood vessels form. Functional integration occurs by 17th day but the tissue is mophologically distinct for months. After 24 weeks graft shrinks 25% when placed on denuded bone & 50% when placed on periosteum.

  37. 2.PEDICLE AUTOGRAFT LATERALLY (HORIZONTALLY) DISPLACED FLAPS- Described by GRUPE & WARREN- STEPS- STEP 1- PREPARE THE RECIPIENT BED- STEP 2- PREPARE THE FLAP STEP 3- TRANSFER THE FLAP STEP 4- PROTECT THE FLAP & DONOR SITE

  38. CORONALLY DISPLACE FLAP- STEP 1- Two vertical incisons beyond mucogingival junction. Elevate flap STEP 2- Scale & root plane tooth suface. STEP3- return flap & suture it.

  39. 3. SUBEPITHELIAL CONNECTIVE TISSUE GRAFT ( LANGER) Indicated for multiple defects with good vestibular depth and gingival thickness. STEPS- STEP 1- 2 horizontal incison & two vertical incisons extending 1 -2 mm away from gingival margin. Extend the flap to mucobuccal fold. STEP 2- Scale & root planing STEP 3- Obtain connective tissue graft from palate. STEP 4- Place connective tissue on denuded root surface & suture it. STEP 5- Cover the graft with partial thickness flap & suture it interdentally

  40. bibliography Goldman, H. M., PERIODONTIA. Ed. J, St.Louis, 1953, C. V. Mosby Co., pp. 552-561 Friedman N. Mucogingival surgery. Tex Dent J 1957;75:358-362 Consensus report on mucogingival therapy. Ann Periodontol 1996;1:702-706 Dewel BF. The normal and the abnormal labial frenum: clinical differentiation. J Am Dent Assoc. 1946;33:318- 329. Henry SW, Levin MP, Tsaknis PJ. Histologic features of superior labial frenum. J Periodontol. 1976;47(1):25-28. Bhaskar SN, ed. Orban s Oral Histology and Embryology.11th ed. St. Louis, MO: Mosby Year Book; 1991:301. Sewerin I. Prevalence of variations and anomalies of the upper labial frenum. Acta Odontol Scand. 1971; 29(4):487-496 Mirko P, Miroslav S, Lubor M. Significance of the labial frenum attachment in periodontal disease in man. Part I. Classification and epidemiology of the labial frenum attachment. J Periodontol 1974;45:891-4. Angle EH: Treatment of malocclusion of the teeth, 7th Ed. Philadelphia: SS White Co, 1907. Tait CN: The median fraenum of the upper lip and its influence on the spacing of the upper central incisor teeth. NewZealand Dent J 20:5-21, 47-65, 1929. Ceremello PJ: The superior labial frenum and the midline diastema and their relation to growth and development ofthe oral structures. Am J Orthodont 39:120-39, 1933. Aa Bb Friedman N, Levine HL: Mucogingival surgery. JPeriodontol 35:5-21, 1964 Kopczyk RA, Saxe SR. Clinical signs of gingival inadequacy: the tension test.ASDC J Dent Child.1974;41(5):352-5 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

  41. 16. Ainamo J, Loe H: Anatomical characteristics of gingiva. A Clinical and microscopic study of the free and attached Gingiva. J Periodontol 1996; 37:5.

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